by Tilda Shalof
“Now you really do look like the Michelin man,” I say to the patient (who still has shown few other reactions besides groaning and moving his eyelids). But I feel better to see him neatly wrapped. There’s no bloody drainage on the sheets or the dressings. Things are neat and tidy—at least, as much as possible. When his family comes to visit, he’ll look better to them, I’m sure. Donna and I appraise our handiwork and smile at each other: a job well done.
As I sit outside the room, writing up my notes, one of the other nurses comes up to me and says, “While you’re here … would you mind taking a look at my patient?”
“Sure” I say, “just give me a minute to finish this.”
I love what I do. I’m a needed resource, there to help patients, their families, and the ICU staff grow and develop. As I see it, the more apple trees, the better.
Discernible Markings
Claire Thomas, RN, BScN
IT WAS A FRIDAY NIGHT and I was a little late arriving to work. I rushed to my assigned room and found an empty bed: this is an ominous sign in a trauma unit. I had worked in intensive care for six years, but only two in trauma; I was still considerably green. I set up the room to ensure it was well stocked and well equipped, prepared for anything from gunshot wounds to a motor vehicle crash.
The notion of not knowing the night’s fate is always daunting. This empty bed would soon be filled by someone with a specific, serious situation. Everyone in ICU knows that feeling of being nervous yet simultaneously mentally preparing for a plethora of possible admissions, but few of us discuss it. Personally, I refrain from talking about it because, although I have chosen this profession and often thrive on the excitement and adrenaline rush, I’m aware that for the patients and their families, our meeting signifies the worst of all possible circumstances.
When I was satisfied that my room was ready, I made a round of the ICU to see whether any of my colleagues could use a hand—or more accurately, to socialize and to distract myself.
Not even an hour had passed when the charge nurse informed me that a multi-trauma victim was en route to the hospital. A pedestrian, in her mid-thirties, had been struck in a hit-and-run accident. So far, that was all we knew. Still nameless, “Jane Doe” was being admitted through Emergency, where our ICU’s medical resident had been sent to perform a quick assessment. I was sent to meet them in CT scan with the bed. The victim had been intubated on the scene and several large-bore IVs had been started, but I knew they wouldn’t be enough. After such a massive trauma, she would need resuscitation with large amounts of fluid, so we would need to put in a central line in order to access a main vein. We could see that she had lost a huge amount of blood, and she was likely bleeding internally, too.
As I received a brief verbal report from the attending physician about the patient’s visible injuries, I watched over the radiology technician’s shoulder to view the internal injuries of my patient on the screen. The picture was bleak. There was a small right hematoma in the parietal lobe of the brain, but no noticeable shift; a fractured mandible (jawbone), multiple rib fractures, causing a right hemopneumothorax, which is an accumulation of blood and/or air in the pleural cavity; a likely liver laceration; a pelvic fracture; and left tibia and fibula fractures. We would know more once we received the final report from the radiologist. My immediate concern, however, was that my patient’s vital signs were worsening: her heart rate was increasing, blood pressure decreasing—she was intravascularly dry.
We rushed her up to ICU and into my assigned bed space. My colleagues, the other critical care nurses, freed themselves to come over and help. We had so much to do to stabilize the patient that none of us had even a moment to consider the tragedy or the person who lay before us. I delegated assignments. One nurse connected the patient to the cardiac monitor while another began setting up IVs and priming meds. Two others worked on the patient directly, cleaning her wounds and applying dressings. The respiratory therapist (RT) connected her to the ventilator while I drew blood samples. Someone called the blood bank to advise their staff that we needed a lot of products, stat. The attending inserted an arterial line and was preparing to insert a central line when the thoracic surgeon on call arrived to see whether his specialized skills were needed.
My patient’s vital signs were still labile. I gave her Pentaspan, a volume expander, as well as normal saline boluses, one after another. I knew that I would have to keep on top of her fluid requirements all night. I initiated Levophed, a potent inotrope, in order to maintain her blood pressure. She was barely alive. I think we were all afraid we would lose her, but we couldn’t stop to allow our minds to go there.
The surgeon decided to insert a chest tube in order to evacuate the blood from the patient’s chest cavity and to reinflate her collapsed lungs. The nurses set up the instruments and equipment while the doctor began draping the patient with a sterile sheet. At that moment, the first of many units of packed red blood cells and fresh frozen plasma was being checked and, using a device called the rapid infuser, transfused as quickly as possible.
During the few moments of the chest tube insertion, because the patient was now under a sterile field and there wasn’t much for me to do besides adjust a few medications and watch the monitor, I finally had an opportunity to look at the situation in front of me.
The patient was a mess and the room was a mess. Bloody linen, overflowing garbage cans, over a dozen IV lines infusing various drugs and blood products, the ventilator chirping alarm warnings—it was chaos. But this was purposeful, organized chaos. I knew from my ICU experience the reason for all of this chaos. This was a person, with a life, family, and friends, and I hoped our efforts would not be in vain.
“I got it,” I heard the surgeon say and was quickly brought back to reality. I handed him the tubing for the chest tube drainage system and connected it to wall suction. Immediately a liter of frank, or bright red, blood drained into the canister. I paged for a portable chest x-ray so that I could confirm correct placement of the chest tube and continued to closely monitor her vital signs while the chest tube was being sutured in place. I drew repeated blood gases to ensure ventilation was optimal and discussed with the RT the appropriate adjustments to be made on the ventilator. The monitor was beginning to read near-normal signs of life: HR 110, BP 100/55, O2 Sat at 98 percent. It looked like the situation was improving.
However, there was another worrisome sign: my patient was continuing to bleed from the wounds all over her body. I started changing her dressings, beginning at the open laceration to her left knee and lower leg, likely from the bumper of the car. I applied a silk gauze hemostat, which helps in clotting, directly to the wound in the hopes of easing some of the ongoing bleeding. I worked my way up her body, cleaning and dressing each skin tear and scrape. I rinsed her mouth, which was full of blood, and packed her bleeding nose. I applied small bandages to the cut above her brow and wiped more blood from her face. Despite her gruesome injuries, I could tell she was a pretty, well-groomed woman. She had manicured and polished nails; her long hair even now had some evident style.
I performed another neurological assessment. There were no improvements, no signs that she was waking up. Her pupils were equal and reactive to light, but her score on the Glasgow Coma Scale was a 3—the lowest possible score. She was not moving nor opening her eyes. She was completely unresponsive. The situation was looking very grim.
We still didn’t know her identity. She was a nameless accident victim.
She began to shiver. I tried to take her temperature but it was so low it was undetectable. I called for an electric warming blanket and set it to high. The portable x-ray arrived and using full CTL (cervical, thoracic, and lumbar) spine precautions, four of us rolled the patient onto the board.
By this point, the patient’s face had swollen extensively from her injuries as well as the fluids we had infused. It would have been difficult for anyone, even her family, to recognize her. Her eyelids were swollen and a deep red-purple. Her face
had swollen around the ties holding her endotracheal tube in place. She had a large hematoma extending from her right shoulder down her chest and abdomen. As I did another visual head-to-toe assessment, I suddenly recognized the marking across her lower abdomen and pelvis. It was tire tracks. I was completely taken aback. The room fell silent, as though everyone around me noticed the same marking at the same time. A knot formed in my stomach. I wasn’t ready to acknowledge that the car that hit this poor woman had in fact rolled over her. I didn’t know what to think or how to react. I remember feeling angry but there wasn’t time and I knew it wouldn’t be appropriate to become emotional.
We had to get her off the x-ray board. I secured her head and cervical spine and on the count of three we rolled her. Suddenly, the patient began deteriorating again. She began to lose more blood than we could replace and her left pupil had now blown. It was fixed and dilated.
In less than four hours, I had gone from giggling with colleagues to caring for a patient with major traumatic injuries, and now, most certainly, to witnessing a tragic loss of life.
Still, I continued to do everything in my power to ensure that this patient would survive at least until her family arrived and had a chance to say good-bye. The doctor was aware I had increased her meds to nearly triple that of the recommended doses in order to try to maintain her vitals. I continued to give fluid boluses, alternating between saline and blood transfusions. She began to have arrhythmias despite my frequent checks and corrections of her serum electrolyte (sodium, potassium, calcium, magnesium, and phosphate) imbalances.
Finally, the call came. My patient’s next of kin had been located. Our “Jane Doe” was Tracy Hammond. I braced myself as I went out to the hallway to meet her family. There was just one visitor, a man close in age to the patient, tall, with a noticeably strong build but looking weak with fear. I introduced myself and briefly described Tracy’s injuries, trying to prepare him for what he would see when he entered the room: the ventilator, the monitor, tubes running in and out of his loved one’s body, the bruising. As I spoke, his expression remained flat. He didn’t say a word, only nodded yes when I asked if he was ready to come to the bedside.
I had done my best to make Tracy as presentable as possible, wiping off the blood, changing the oozing dressings, and covering her shocking wounds with pristine linen, but there was no denying it—it was a tragic scene and despite my efforts, she looked horrible.
The two nurses who I had left at the bedside to monitor and titrate drugs stopped and stepped away; now, the visitor took precedence. Peter, as I later learned, was Tracy’s fiancé. They had recently moved to the city, leaving their families for job opportunities, so Peter was her only local next of kin. He approached the bed slowly and stood at a distance, staring at her.
I had the doctor paged and arranged for a conference room so that the three of us could discuss the situation. When the doctor arrived, I directed Peter to the room, discreetly grabbing a box of tissues on my way in. We sat down and Dr. Roberts introduced himself and offered his sympathy. He ran through, in lay terms, the full extent of Tracy’s injuries and that they were likely too extensive for her to survive. He told Peter straight out that Tracy was going to die.
Peter sat there, with very little visible emotion, only rubbing his hands together as he listened. He was asked to decide whether we should continue a probably futile resuscitation or begin the process of withdrawal. Peter had very few questions but asked if he could have a minute to gather his thoughts. Dr. Roberts and I left the room and returned to Tracy Hammond’s bedside. We stood at the foot of the bed in silence, waiting for instruction on how to proceed. In the meantime, despite our efforts, it looked like the decision would be made for us—Tracy was “declaring herself.”
Not yet allowed to give up, we pressed on, increasing drips and hanging yet another fluid bolus, but it was becoming clear that Tracy was going to die. Peter stood in the doorway of Tracy’s room. His eyes were red from crying. He said he had spoken with Tracy’s parents and sister, who all lived in Montreal, and they all agreed. “Tracy wouldn’t want to be this way,” he said and asked for everything to be stopped, for us to now leave her alone. He walked over to her side and this time reached for her hand. Then he began tearing up; he kissed her forehead and walked out of the room.
Peter couldn’t bear to stay for long. He was clearly uncomfortable being in the hospital and seeing Tracy in that state. I followed him out to the waiting room to make sure he was okay. He told me they had been engaged for two years but were so busy they still hadn’t set a date. I tried to comfort him with all the clichés I could think of, but I don’t think either of us bought it. He thanked me and, shaking my hand, said he couldn’t stay and watch her die. That was it. He left; it was now up to me to be with Tracy in her dying moments.
The doctor was at my desk, writing orders in the chart and documenting the meeting with Peter. I walked back into the room and began turning off the drips. I grabbed a face cloth and again wiped the blood from Tracy’s face. I had never met or spoken to her, yet I felt a definite personal connection. We were so close in age. I couldn’t understand how Peter could leave, but I certainly wouldn’t let Tracy be alone. I pulled a chair to the side of the bed, dropped the side rail down, and sat holding her hand. I watched the monitor display her changing heart rhythm; her blood pressure was dropping. It wasn’t long before the various alarms began to ring. I stood up and checked her carotid. Tracy was dead.
I felt someone behind me holding my shoulders; it was Steve, one of the nurses who had been helping me. Neither of us said anything; we didn’t need to. Together, we collected the equipment and washed her body before wrapping it. When I finished my charting, it was 4:30 A.M. and I was exhausted. The rest of the night was quiet. At 7:15 I changed out of uniform and left the hospital. I took an alleyway and barely made the corner off the main road before I broke down sobbing. I cried the whole way home.
Visiting Hours
Mary Malone-Ryan, RN, BN
IT WAS SUNDAY NIGHT. I drove to work, passing as usual the Catholic church that always looked so solemn beside the road, and did my ritual of blessing myself as I asked God if He could again do rounds with me this night shift. I also asked that He give me an extra dose of patience and wisdom tonight because I’d been unable to rest that afternoon before night shift. If I can get in a nap before work, it helps me work well during the night.
When I got to the ICU, I noticed that Room 286 was full of family members. This was unusual at shift change—to be honest, it was highly unusual in our ICU because the visiting hours were clearly defined and we went to great lengths to enforce this rule. Why are they here after visiting hours? I wondered to myself. I looked up at the assignment board and realized that that was my patient in Room 286.
I sat down, and the RN from the day shift who was about to give me her report broke away from the family to tell me, “Oh, Mary, I’m sorry to leave this with you, but we had to wait until all the family members were present.” She pulled up a chair and sat beside me at the nursing station. We huddled together as she opened the patient’s chart. The doctor’s order answered my question regarding the family’s presence after hours. “EXTUBATE this evening with all the family members present at patient’s bedside,” it read. That simple directive didn’t come close to capturing what lay before me, my patient, and his family, in the long night ahead.
The day RN explained why she had not extubated her patient: “He’s Hmong,” she said. “They have a tradition of dressing a dying person in his own clothes before he dies, and they’re not finished yet.” I glanced at my watch; it was 6:48. This poor family doesn’t even know me, I thought to myself. As far as they’re concerned, I’m a complete stranger, and soon I’ll be the one coming in to take their loved one off the ventilator. Soon after, he will die. I, the stranger, will be trying to offer them comfort during this tragic time in their lives.
Mr. Chu was 51 years old. He had a wife and six children. He had
had a lung transplant a year ago and now a massive bleed in his head had caused so much damage that there was very little brain activity. The RN accompanied me to Room 286, hugged the wife, and introduced me to the family. “This is Mary. She will be your husband’s nurse tonight.”
I will also be your nurse tonight, I thought to myself. That’s one thing I’ve learned in my long career as an ICU nurse: in these situations, the family is as much a part of your concern as the patient is.
Mr. Chu’s small body was hooked up to the familiar intravenous pumps and monitors, as well as the ventilator. But he was dressed in unfamiliar garb: the green hospital gown was replaced with a gray suit and white shirt, and a beautiful brightly colored cloak was underneath him. His wife and his mother were meticulously making sure every button was buttoned and every zipper was zippered. The wife looked at me, “I cannot get his pants all the way on; could you help me?” I looked down: the Foley catheter was the obstacle. So, with every family member’s eyes on me, I ever so gently manipulated the catheter through his pants, allowing them to zipper and button the pants. The wife then pulled the cloak up over his shoulders and nodded to her eldest son. The son said, “We are ready.”
I began to perform my initial assessment. Pupils were dilated, no reaction to light; chest sounds were clear but decreased to the bases; heart sounds S1 and S2 were audible; no bowel sounds; no pulses detectable in the feet; there was trace edema and mottling at the tips of his toes.
